Medicare Opt Out: What You Need to Know

Medicare Opt Out: What You Need to Know

By Dr. Valerie Martinsen Seifert 

Medicare covered dental services are few and far between, perhaps nonexistent for many dentists, so the changes in Medicare rules have not felt very important until they got more complicated.

In 2015, The Centers for Medicare and Medicaid Services (CMS) announced a new rule to combat fraud and abuse in Medicare Part D. At that time, dentists and other physicians and practitioners were presented with a mandate to either Opt Out or enroll in Medicare so that prescriptions or lab tests ordered for their patients with Medicare would be covered. If a dentist were to choose either option, Medicare patients would receive their benefits.

By April 2018, CMS released the final version of this rule that revised the regulations on dentists who might provide dental care or prescriptions for patients with Medicare Advantage (Part C) or Prescription Drug Benefits (Part D). Under the new rule, dentists no longer needed to take any action to provide Medicare Advantage services or have prescriptions they order be covered under Medicare Part D. In fact, a dentist who is Opted Out is not eligible to be reimbursed by Medicare Advantage plans. However, if ordering or referring laboratory or imaging services, a dentist is still required to Opt Out or Enroll for Medicare patients to receive their benefits.

If you were proactive when the rule was first proposed and did not delay in Opting Out of Medicare (because you don’t provide dental services covered under traditional Medicare or order/refer lab or imaging services), then you may be surprised to find that due to the rule change announced in 2018, you have spent the last few years Opted Out of Medicare without any benefit. In addition, you’ve been unable to be reimbursed by Medicare Advantage plans, nor could your patients file their own claims. If you chose to Opt Out after June 2015, your Opt Out status has been automatically renewed every two years.

According to CMS, a practitioner must submit their written notice to each Medicare Administrative Contractor to Opt Out or to cancel their Opt Out status at least 30 days before the renewal date. There are 120 dentists in Indiana who have Opted Out but may not want to maintain that status. If you are a dentist who has been Opted Out and orders or refers patients for laboratory or imaging services, you may want to enroll in Medicare in order to receive reimbursement for these services as well as Medicare Advantage services. If you do not provide Medicare services or referrals, you may now benefit more from having no Medicare status rather than being Opted Out. Your patients with Medicare will have their prescriptions covered and be able to use their Medicare Advantage benefits for dental care. For more information, see the informative flow chart from the ADA.


If You Need to Take Action 

If you are unsure of your Medicare status, you can view the list of Opt Out Affidavit practitioners by “view data” then “filter” to your name or other details here.

To rescind your Opt Out status, contact each Medicare Administrative Contractor that you initially filed with in writing. In Indiana, Medicare is administered by Wisconsin Physicians Service Government Health Administrators:

WPS GHA Provider Enrollment Unit
P.O. Box 8248
Madison, WI 53708-8248

To enroll as a full Medicare Provider (form CMS-855i) or a Medicare Ordering/Referring Provider (from CMS-855O), visit or follow this link.


Sources cms-finalizes-rule-rescinding-parts-c-d-enrollment-requirements


Dr. Valerie Martinsen Seifert is a general dentist in LaPorte. She currently serves as President-Elect of the Northwest Indiana Dental Society and on the IDA Dental Benefits Subcommittee. She also is a graduate of the IDA AIR Program.

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